David E. Bolger, Attorney at Law

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1 WORKSHEET GUIDELINES David E. Bolger, Attorney at Law 506 Wilkesboro Blvd. Ste 230 Lenoir, NC Phone: Fax: Visit our website at Please print clearly and neatly. The Bankruptcy process is delayed when information is missing or difficult to understand. All forms must be filled out completely. Please use the customer service addresses for creditors. Without a correct address, a creditor will not receive notice of Bankruptcy and the debt cannot be discharged. In the event of a pending Foreclosure, please provide the court documents you were served. This provides information regarding the hearing and sale date. As long as you qualify to file for a Chapter 13 based on income and expenses, we will make every effort to file the case before the Foreclosure Procedure. Please return completed forms to us. Work will begin once the fee has been paid in full. Attorney fee is non-refundable. Please do not hesitate to call if you have any questions filling out the forms. You may also me at dave@davebolgerlaw.com please put bankruptcy questions in the subject line. YOU ARE REQUIRED TO BRING THESE DOCUMENTS WHEN YOU TURN IN YOUR COMPLETED PAPERWORK. 1. Proof of income for last 6 months prior to filing (ex. If you file in May, we need income from November-April) (ALL pay-stubs or printout from employer showing gross income and ALL deductions) 2. Driver s license and social security cards. 3. Last Two Years Tax Returns 4. Proof of Automobile and Homeowner s Insurance 5. Registration Cards for all Vehicles. 6. Credit Counseling Step butterflyfe.com 1

2 David E. Bolger, Attorney at Law Client Questionnaire How did you hear about my office? If phone book, which one? FILING INFORMATION Joint Individual Corporation Marital Status: Married Divorced Separated Widowed FULL NAME: Have you used other names in the last 6 years? Yes No If yes, list other names: Social Security # Street Address: Home Phone: City: State: Zip: County: Work Phone: If you have a different mailing address or use a post office box, please list: SPOUSE INFORMATION: FULL NAME: Have you used other names in the last 6 years? Yes No If yes, list other names: Social Security # If you have a different mailing address or use a post office box, please list: Have you or your spouse ever filed bankruptcy before? Yes No If so, please provide us with copies of the bankruptcy paperwork. Case Number: Date Filed: Place Filed: Previous Credit Counseling Name of Credit Counseling Agency: Address: Phone #: Was there a charge for this service: How Much Per Month Last date payment this year: HAS THIS LAW FIRM OR ITS ATTORNEYS EVER REPRESENTED YOU BEFORE? Yes No If yes, please explain: 2

3 ASSETS/BELONGINGS/PROPERTY Note: You must list EVERYTHING that you own for me to properly advise you. OUR OBJECTIVE IS TO PROTECT ALL OF YOUR BELONGINGS LAND/REAL ESTATE: (Please go to the next section if you own a mobile home, but not the land.) The term value does not mean what is owed on the property; it means the amount for which you could currently sell the item. 1. Residence: List Complete Description and Address of Property: (i.e., 2 bedroom frame house on 1 acre of land at 1 Easy St., Hickory, NC) Description: Acreage: Street Address: City: State: Zip: Owned By: Husband Alone Wife Alone Jointly Owned Market Value: _ Tax Value: _ Do you want to: Keep Making Payments Surrender the Home Paid for First Mortgage Bank: Mortgage Payoff: $ Address: Account #: City: State: Zip: Origination Date: Are you current on payments? If no, exact arrearage amount $ Months behinds: Interest Rate: Monthly Payment: Second Mortgage Bank: Mortgage Payoff: $ Address: Account #: City: State: Zip: Origination Date: Are you current on payments? If no, exact arrearage amount $ Months behinds: Interest Rate: Monthly Payment: 2. Other Real Estate: Description: Date of Purchase: Street Address: City: State: Zip: Names of Deed: Tax Value: Do you want to: Keep Making Payments Surrender Paid for Mortgage Bank: Mortgage Payoff: Address: Account #: City: State: Zip: Are you current on payments? If no, exact arrearage amount $ Months Behind: Interest Rate: Monthly Payment: 3

4 FINANCIAL ASSETS Cash on Hand: Bank Accounts: (Checking, Savings, CDs, etc ) 1. Type of Account: Balance: $ Bank: Address: City: State: Zip: Name(s) on Account: 2. Type of Account: Balance: $ -_ Bank: Address: City: State: Zip: Name(s) on Account: 3. Type of Account: Balance: $ -_ Bank: Address: City: State: Zip: Name(s) on Account: Retirement Account: 1. Name on Plan: Type of Plan: Employer: Address: City: State: Zip: Balance: $ Any Loans against account: Loan Balance: $ 2. Name on Plan: Type of Plan: Employer: Address: City: State: Zip: Balance: $ Any Loans against account: Loan Balance: $ Employee Benefit Plan: 1. Name on Plan: Type of Plan: Employer: Address: City: State: Zip: Balance: $ Any Loans against account: Loan Balance: $ 2. Name on Plan: Type of Plan: Employer: Address: City: State: Zip: Balance: $ Any Loans against account: Loan Balance: $ IF you have filed your tax return, but you have not received a refund yet, how much do you expect to receive? $ IF you have not yet filed a return but you expect a refund, how much do you expect to receive? $ 4

5 Life Insurance Policies 1. Company: Name on Policy: Address: City: State: Zip: Type of Policy: Term (No Cash Value) Whole (Cash Value) Beneficiary: Relationship to you: 2. Company: Name on Policy: Address: City: State: Zip: Type of Policy: Term (No Cash Value) Whole (Cash Value) Beneficiary: Relationship to you: 3. Company: Name on Policy: Address: City: State: Zip: Type of Policy: Term (No Cash Value) Whole (Cash Value) Beneficiary: Relationship to you: Stocks/Bonds Name/Address: Value: $ Name/Address Value: $ Security Deposits (landlord, electric, phone, utility, etc ) 1. Held by: Amount of Deposit: $ Address: City: State: Zip: 2. Held by: Amount of Deposit: $ Address: City: State: Zip: Are you Expecting a Gift, Inheritance, or Settlement in the next 180 days? 5

6 HOUSEHOLD ITEMS/PERSONAL PROPERTY NOTE: Value means what the item is currently worth not what you paid for it; not what you owe against it; not what it would take to buy the item again new. Some attorneys and trustees use a yard sale value. IF SOMETHING IS NOT ITEMIZED, PLEASE LIST IT IN THE OTHER BOX. Description Value Description Value Stove $ Clothing $ Refrigerator $ Wedding Rings $ Freezer $ Other Jewelry $ Washer $ Pictures $ Dryer $ Decorative Objects $ Small Kitchen Appliances $ Books $ Kitchen Table & Chairs $ Animals (type & value) $ Silverware & Dishes $ Firearms Living Room Furniture $ Model $ Dining Room Furniture $ Model $ Den Furniture $ Model $ Master Bedroom Furniture $ Power Tools $ Children s Bedroom Furniture$ Hand Tools $ Other Bedroom Furniture $ Lawn Tools $ TV(s): How Many $ Vacuum Cleaner $ VCR(s): How Many $ Computer $ DVD Player $ Printer $ Camcorder $ CDs $ Satellite Dish $ DVDs $ Radio $ Tapes $ Stereo $ Coin/Stamp Collection $ OTHER (description and value) Attach other sheets if necessary. BUSINESS ASSETS (if self-employed or own your own business) Business Tools: Description and Value Business Equipment: Description and Value Business Inventory: Description and Value 6

7 DEBTS SECURED BY PERSONAL PROPERTY (Not Real Estate or Vehicles) 1. Creditor: Account #: Mailing Address: Payoff: City: State: Zip: Date of Loan: Debtor: Co-Debtor: Co-Debtor s Address: Did you purchase the item(s) from the creditor you previously owned items Monthly Payment: Interest Rate: Has this debt been turned over to a Collection Agency or an Attorney? If so, Name: Address: City: State: Zip: 2. Creditor: Account #: Mailing Address: Payoff: City: State: Zip: Date of Loan: Debtor: Co-Debtor: Co-Debtor s Address: Did you purchase the item(s) from the creditor you previously owned items Monthly Payment: Interest Rate: Has this debt been turned over to a Collection Agency or an Attorney? If so, Name: Address: City: State: Zip: 3. Creditor: Account #: Mailing Address: Payoff: City: State: Zip: Date of Loan: Debtor: Co-Debtor: Co-Debtor s Address: Did you purchase the item(s) from the creditor you previously owned items Monthly Payment: Interest Rate: Has this debt been turned over to a Collection Agency or an Attorney? If so, Name: Address: City: State: Zip: 7

8 BOATS/VEHICLES (i.e., 2002 Honda Civic Sedan 4 Door LX 45,000 miles) 1. Year/make/model: Mileage: Lien Holder: Account #: Address: City: State: Zip: Whose name is it in? Year Purchased: Payoff: $ Is there a co-debtor? If so, list Name & Address: Monthly Payment: Interest Rate: Do you want to: Keep Making Payments: Surrender It is paid for: 2. Year/make/model: Mileage: Lien Holder: Account #: Address: City: State: Zip: Whose name is it in? Year Purchased: Payoff: $ Is there a co-debtor? If so, list Name & Address: Monthly Payment: Interest Rate: Do you want to: Keep Making Payments: Surrender It is paid for: 3. Year/make/model: Mileage: Lien Holder: Account #: Address: City: State: Zip: Whose name is it in? Year Purchased: Payoff: $ Is there a co-debtor? If so, list Name & Address: Monthly Payment: Interest Rate: Do you want to: Keep Making Payments: Surrender It is paid for: 4. Year/make/model: Mileage: Lien Holder: Account #: Address: City: State: Zip: Whose name is it in? Year Purchased: Payoff: $ Is there a co-debtor? If so, list Name & Address: Monthly Payment: Interest Rate: Do you want to: Keep Making Payments: Surrender It is paid for: Have you listed absolutely everything that you own or otherwise have a right to claim? Yes No We must know about all belongings in order to provide protection for them. 8

9 PRIORITY CLAIMS (USUALLY WILL BE PAID BACK IN FULL) 1. Student Loan Name of Lender: Account #: Address: City: State: Zip: Payoff: Debtor: 2. Unpaid Alimony or Child Support Payments sent to: Debtor: Address: City: State: Zip: Amount past due: Amount/Month: 3. Unpaid Past Due Taxes In the past 10 years, have you filed each year? Yes No If not, list year(s) missed: Federal Taxes Filing Year: Amount Owed: $ Was a Return Filed: If so, in whose name: IRS Lien? Filing Year: Amount Owed: $ Was a Return Filed: If so, in whose name: IRS Lien: State Taxes Filing Year: Amount Owed: $ Was a Return Filed: If so, in whose name: Type of Tax: Filing Year: Amount Owed: $ Was a Return Filed: If so, in whose name: Type of Tax: County Taxes County: What Type of Property Tax: Address: City: State: Zip: Year: Amount Owed: $ Account Number: County: What Type of Property Tax: Address: City: State: Zip: Year: Amount Owed: $ Account Number: 9

10 UNSECURED DEBTS: (credit cards, medical bills, personal loans (without collateral) or any one else to whom you owe money. **Use correspondence or customer service address only, NOT payment address** 1. Name of Creditor: Account #: 2. Name of Creditor: Account #: Co-Debtor? If so, Name and Address: Name of Creditor: Account #: 10

11 4. Name of Creditor: Account #: 5. Name of Creditor: Account #: 6. Name of Creditor: Account #: 11

12 7. Name of Creditor: Account #: 8. Name of Creditor: Account #: 9. Name of Creditor: Account #: 12

13 10. Name of Creditor: Account #: 11. Name of Creditor: Account #: 12. Name of Creditor: Account #: 13

14 13. Name of Creditor: Account #: 14. Name of Creditor: Account #: 15. Name of Creditor: Account #: 14

15 ATTACH OTHER SHEETS AS NEEDED. DID YOU LIST ABSOLUTELY EVERY ENTITY TO WHOM YOU OWE MONEY (BANKS, FINANCE COMPANIES, MEDICAL BILLS, FAMILY MEMBERS, COMPANIES, ETC )? YES NO FAMILY INFORMATION: Must provided spouse income and expenses, even if not filing jointly. Marital Status: Married Single Divorced Widowed Children or Other Dependents Age: Relationship: In Home? Yes No Age: Relationship: In Home? Yes No Age: Relationship: In Home? Yes No Age: Relationship: In Home? Yes No Age: Relationship: In Home? Yes No EMPLOYMENT INFORMATION Debtor (Husband if filing jointly) Employer: Occupation: Address: City: State: Zip: Years with Employer: Second Job? Same info. As above: Spouse (Wife if filing jointly) Employer: Occupation: Address: City: State: Zip: Years with Employer: Second Job? Same info. As above: 15

16 Average Income from Wages (Even if you are not paid the same amount each check, please try to average out what you usually bring home, including overtime. If possible, please attach a normal/average pay stub.) If you are self-employed or receive governmental assistance, go to Other Income. INCOME HUSBAND WIFE How often are you paid? What is the usual income (GROSS) DEDUCTIONS (each pay period) Taxes/Social Security/FICA Insurance 401(k), Retirement Contribution 401(k) Loan Payment United Way Child Support/Alimony Other Deductions What is the usual take home pay (NET) OTHER INCOME: Please state whether husband or wife. Business Income before paying expenses (monthly average) $ Support: $ Social Security $ Alimony:$ Disability $ Rental: $ Retirement/Pension $ Other Income Specify Source: $ $ WILL THERE BE A DEFINITE CHANGE IN INCOME OF MORE THAN 10% IN THE NEXT YEAR? YES NO If yes, please explain: 16

17 AVERAGE MONTHLY LIVING EXPENSES PLEASE SHOW MONTHLY AMOUNTS OF EXPENSES BELOW: Rent or Home Mortgage (add 1 st and 2 nd mortgages) Real estate taxes included Yes No Property insurance included Yes No Electricity and Heating Water and Sewer Telephone Cable Television Service Home Maintenance (repairs and upkeep) Food Clothing Laundry and Dry Cleaning Medical & Dental Expenses (out of pocket) Transportation Expenses (gasoline, repairs, etc) Recreation, Entertainment, Newspapers, etc. Insurance (not deducted from paycheck or in mortgage) Homeowners or Renters Life Health Automobile Other Taxes (not deducted from paycheck or in mortgage) Real Estate Self Employment Vehicle Installment payments for car, furniture, etc. after bankruptcy Specify: Specify: Specify: Alimony or child Support (not deducted from check) Regular Expenses from Business Childcare Expenses Baby Expenses Pet Expenses Internet Expenses Personal Care, Postage, etc Other Expenses (PLEASE LIST) 17

18 DO NOT LEAVE BLANK!!! ANNUAL INCOME-must be filled in completely. If married, then what each made. Period Husband Wife Year to Date Last Year Prior Year OTHER INCOME (Social Security, Disability, Support, Alimony, etc.) Period Husband Wife Year to Date Last Year Prior Year MISCELLANEOUS QUESTIONS 1. If you add up every payment paid to each creditor in the last 90 days (3 months), has a single creditor received $600 or more from you (total of all payments to that creditor) in that time period? Yes No If so, please complete: Creditor Name Date(s) of Payments Amount Paid 2. Have you made any payment to a family member, friend or other related individual in the last year? Yes No If so, please complete: Name Date(s) of Payment Amount Paid Relationship 18

19 3. In the last year, have you been sued or otherwise been a party to any legal proceeding in court? Yes No If yes, please complete: Plaintiff Name: Defendant Name: County where filed: Court where filed: Case Number: Date of Hearing/Trial: Address of Plaintiff or Attorney: Amount of Claim: 4. Do you have any judgments against you? (In the last 10 years or 20 years if renewed)? Yes No If yes, please complete. (Must be completed in full or attach a copy of the judgment page with the book number written on it.) Plaintiff Name: Defendant Name: County where filed: Court where filed: Case Number: Date of Hearing/Trial: Address of Plaintiff or Attorney: Judgment Book & Page Number: Date Entered: Amount of Judgment: 5. Repossessions, foreclosures, or returns of collateral to a creditor in the last year: Creditor Name/Address Collateral/Value Date Amount Owed 6. Has a lender ever said that you owed the lender any amount following a repossession, foreclosure, or return other than listed in #5? Yes No If yes, please complete: Creditor Name/Address Collateral/Value Amount Sill Owed 19

20 7. Gifts or donations in the last year to a single church or charity totaling (to that single church or charity) over $100. Church or Charity Name/Address Value/Donation Date(s) 8. Gifts in the last year to a family member or close friend that would total more than $200? Name/Address Relationship Date Amount 9. Losses in the last year to fire, theft, other casualty, or gambling: How loss occurred Date Description/Value of Property 10. Have you owned anything of value in the last year that you do not own now? (i.e., have you sold or given away anything or value like real estate, vehicles, jewelry, guns, bank accounts, etc. in the last year)? Yes No If yes, please complete: Belonging/Property/ Date of Name/Address of Person Asset and Value Transfer to whom transferred 11. List all closed bank accounts, closed IRAs, closed 401K s or other financial or retirement accounts in the last year: Type of Account Name of Institution Date Closed Amount Taken out at Close 12. Safe deposit boxes in last year: Name of Institution Date Closed (if applicable) Contents 20

21 13. Have you had another address in the last 2 years? Yes No If yes, complete: Address(es) Dates There 14. Do you have anything in your possession that belongs to someone else? If so, describe (name/address of owner, possession description and value): 15. Have you been self-employed in the last 6 years? Yes No If so, complete: Name/Address of Business: Dates of Operation: Name/Address of anyone holding financial records: Dates of Inventories in last 2 years: Partners or Shareholders: 16. Have you lived out of state in the last 6 years? Yes No If yes, were you married at the time to someone with whom you are now divorced? Yes No Please return this completed paperwork to my office along with all the documents that we need listed on the coversheet. Please be aware that if you are filing a chapter 13, your first bankruptcy payment will be due at the time of filing and then you will pay each calendar month after that point. Please keep all check stubs from this point forward, We may need them!! Thank you and if you have any questions or concerns, please feel free to contact me at or by at dave@davebolgerlaw.com I (we) have reviewed the entire Worksheet and have answered all information fully and accurately, to the best of my (our) knowledge and ability. I (we) am (are) unaware of any information that was omitted. I (we) understand that David Bolger, Attorney, will rely on this information in analyzing my financial situation. Date: Signed: Date: Signed: 21

ALL INFORMATION MUST BE FILLED OUT IF NOT APPLICABLE, PLEASE NOTE N/A DO NOT LEAVE ANY INFORMATION BLANK. First Name Full Middle Name Last Name Suffix

ALL INFORMATION MUST BE FILLED OUT IF NOT APPLICABLE, PLEASE NOTE N/A DO NOT LEAVE ANY INFORMATION BLANK First Name Full Middle Name Last Name Suffix Spouse First Name Full Middle Name Last Name Maiden